West Harbour Gardens
Profile & contact details
|Premises name||West Harbour Gardens|
|Address||315 Hobsonville Road Hobsonville Auckland 0618|
|Service types||Dementia care, Physical, Intellectual, Rest home care, Geriatric, Medical|
|Certification/licence name||Sunrise Healthcare Limited - West Harbour Gardens|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||22 August 2023|
|Certification period||24 months|
|Provider name||Sunrise Healthcare Limited|
|Street address||45 William Denny Ave Westmere Auckland 1022|
Progress on issues from the last audit
What’s on this page?
This rest home has been audited against the Health and Disability Services Standards. During the last audit, the auditors identified some areas for improvement.
Issues from their last audit are listed in the corrective actions table below, along with the action required to fix the issue, its risk level, and whether or not the issue has been reported as fixed.
A guide to the table is available below.
Details of corrective actions
Date of last audit: 16 June 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.||Residents and family were not aware of nationwide advocacy services and information around these services was not available.||Provide education and information to residents and family around the nationwide advocacy services.||PA Low||In Progress|
|The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.||There are complaints of rooms not being kept clean and this was observed in some areas on the day of audit.||Ensure that rooms are kept clean at all times.||PA Low||In Progress|
|All records pertaining to individual consumer service delivery are integrated.||Each resident does not have an integrated file.||Ensure that each resident has an integrated file.||PA Moderate||In Progress|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||The 2020 resident/family survey indicated that corrective actions were required to address residents’ issues. Corrective actions identified included providing residents with a session on the code of rights, raise awareness with residents around care plans, remind staff to wear name badges, and complete a food survey. There was a lack of evidence to indicate that these corrective actions had been implemented. Resident meetings also identified issues with no evidence to indicate that the issues… (this text has been trimmed due to space limits).||Ensure corrective actions identified reflect evidence of their implementation.||PA Moderate||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Five of eight staff files selected for review were missing evidence of a completed orientation programme. The remaining three files did have evidence of undergoing orientation, but these were not completed in their entirety. Interviews with a selection of staff indicated that the orientation programme did not successfully prepare them for their job responsibilities.||Ensure all staff are provided with a suitable orientation programme with evidence to support that it is being completed.||PA Moderate||In Progress|
|Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.||There are issues relating to management of residents who smoke that include the potential for residents being asked to supervise another resident who smokes, and the use of areas to smoke outside of the designated area. Since the draft report the provider has stated, there is a smoke area for residents. Staff supervise them when needed. It is not the normal process to ask a resident to supervise another resident who smokes.||Ensure that there is a safe place for residents to smoke with supervision by staff if required.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Interventions were not always documented well in resident files reviewed. Examples are as follows: file one did not include interventions to prevent a pressure injury getting worse (ACC hospital). Catheter and bowel cares were not well documented (ACC hospital). . In file two, there were no interventions documented around management of seizures should they occur (the resident had a history in the past of seizures), and bowel management, while documented did not describe what to do if problem… (this text has been trimmed due to space limits).||Ensure that interventions are documented to manage challenging events or medical issues.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Data from internal audit reports and adverse events is not being reported at the monthly staff meetings.||Ensure that data collected from internal audit reports and adverse events is reported at the monthly staff meetings.||PA Low||In Progress|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||i) The DT was not replaced while on leave and the programme was not provided. ii) An activities plan is not well documented for each resident with interventions identified to meet goals. iii) A 24-hour activities plan was not documented for each resident in the dementia unit that includes their usual routines and activities||i) Provide an activities programme for residents when the DT is on leave. ii) Document an activities plan is for each resident with interventions identified to meet goals. iii) Document 24-hour activities plan for each resident in the dementia unit.||PA Low||In Progress|
|A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.||Five packets of eye drops had not been dated when opened.||Ensure that packets with eye drops or other medicine with a short shelf life are dated when opened.||PA Low||In Progress|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The facility manager reported that he is often unable to fill staff vacancies, that staff are calling in at short notice, or are just not showing up for work. Three weekend days were selected for review. One weekend day (12 June 2021) the AM was short one long and one short shift caregivers, the PM was short one (short) PM shift caregiver and the night was short one caregiver. The next weekend selected (5 June 2021) was short one night shift caregiver. The next weekend day selected (29 May 2… (this text has been trimmed due to space limits).||Staffing vacancies are required to be filled to ensure adequate staffing levels.||PA Moderate||In Progress|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
Whether the required outcome was partially attained (PA) or unattained (UA), and what the risk level of the issue is.
The outcome is partially attained when:
- there is evidence that the rest home has the appropriate process in place, but not the required documentation
- when the rest home has the required documentation, but is unable to show that the process is being implemented.
The outcome is unattained when the rest home cannot show that they have the needed processes, systems or structures in place.
The risk level is determined by two things: how likely the issue is to happen and how serious the consequences of it happening would be.
The risk levels are:
- negligible – this issue requires no additional action or planning.
- low – this issue requires a negotiated plan in order to fix the issue within a specified and agreed time frame, such as one year.
- moderate – this issue requires a negotiated plan in order to fix the issue within a specific and agreed time frame, such as six months.
- high – this issue requires a negotiated plan in order to fix the issue within one month or as agreed between the service and auditor.
- critical – This issue requires immediate corrective action in order to fix the identified issue including documentation and sign off by the auditor within 24 hours to ensure consumer safety.
The risk level may be downgraded once the rest home reports the issue is fixed.
Whether the necessary action is still in progress or if it is complete, as reported by the rest home to the relevant district health board.
Date action reported complete
The date that the district health board was told the issue was fixed.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.
What’s on this page?
Audit reports for this rest home’s latest audits can be downloaded below.
Full audit reports are provided for audits processed and approved after 29 August 2013. Note that the format for the full audit reports was streamlined from 16 December 2014. Full audit reports between 29 August 2013 and 16 December 2014 are therefore in a different format.
Prior to 29 August 2013, only audit summaries are available.
Both the recent full audit reports and previous audit summaries include:
- an overview of the rest home’s performance, and
- coloured indicators showing how well the rest home performed against the different aspects of the Health and Disability Services Standards.
Note: From November 2013, as rest homes are audited, any issues from their latest audit (the corrective actions required by the auditor) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.
Audit reportsAudit date: 16 June 2021
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Partial Provisional Audit
Audit type:Certification Audit
Audit type:Provisional Audit